• Look-back Review Report

      Safety Incident Management Team (SIMT); South /South West Hospital Group (Health Service Executive (HSE), 2018-12-05)
      In September 2017 a major review of CT Scans, Ultrasounds and Chest X-Rays reported by an individual Consultant Radiologist commenced at University Hospital Kerry (UHK). This was prompted by the notification to hospital management of three Serious Reportable Events (SRE) in the category of Care Management Events where a diagnostic error was considered by the hospital's Safety Incident Management Team (SIMT) to have had a serious impact on patients through a delay in diagnosis, limiting treatment options available to them. The matter was escalated to the South/South West Hospital Group (S/SWHG) who recommended that a look-back review would be carried out. This was approved by the National Director of the Acute Hospital Division, HSE, on the 30th of August, 2017. A Group SIMT was then established, chaired by the Chief Operations Officer S/SWHG, to carry out the look-back review. Following the notification of a further Serious Incident (SI) the review was extended in October 2017 to include all images reported by the individual Consultant concerned. Therefore, the review set about auditing 46,234 images in order to identify if there was any missed pathology within the radiology reporting process; to identify if any further patients had been affected; to communicate with them in a timely and appropriate fashion, and ultimately to ensure that patients received appropriate care. The SIMT endeavoured at all times to treat patients with utmost sensitivity and honesty whilst at the same time minimising unnecessary anxiety or distress. Over the course of the look-back eleven patients were identified as having a delay in diagnosis which had an impact on their care. Four of the eleven patients have passed away over the course of the review period. The hospital and the HSE acknowledge that patients and families’ experiences were devastating for them and have had a profound and lasting effect on both the patients affected and their families. The South/South West Hospital Group, University Hospital Kerry and the Health Service Executive (HSE) would like to apologise sincerely and unreservedly to all patients and families harmed by delayed diagnoses.